BackgroundFingertip injuries involving subtotal or total loss of the digital pulp are common types of hand injuries and require reconstruction that is able to provide stable padding and sensory recovery. There are various techniques used for reconstruction of fingertip injuries, but the most effective method is functionally and aesthetically controversial. Despite some disadvantages, cross-finger pulp flap is a relatively simple procedure without significant complications or requiring special techniques.MethodsThis study included 90 patients with fingertip defects who underwent cross-finger pulp flap between September 1998 and March 2010. In 69 cases, neurorrhaphy was performed between the pulp branch from the proper digital nerve and the recipient's sensory nerve for good sensibility of the injured fingertip. In order to evaluate the outcome of our surgical method, we observed two-point discrimination in the early (3 months) and late (12 to 40 months) postoperative periods.ResultsMost of the cases had cosmetically and functionally acceptable outcomes. The average defect size was 1.7×1.5 cm. Sensory return began 3 months after flap application. The two-point discrimination was measured at 4.6 mm (range, 3 to 6 mm) in our method and 7.2 mm (range, 4 to 9 mm) in non-innervated cross-finger pulp flaps.ConclusionsThe innervated cross-finger pulp flap is a safe and reliable procedure for lateral oblique, volar oblique, and transverse fingertip amputations. Our procedure is simple to perform under local anesthesia, and is able to provide both mechanical stability and sensory recovery. We recommend this method for reconstruction of fingertip injuries.

In contrast to the attachments to the pubis and rectum, there is little information on fetal development of the coccygeal attachment of the levator ani muscles. We find that at 9 weeks, the coccygeus muscle is a large muscle facing the piriformis or gluteus maximus and inserting onto the ischial spine, whereas the levator ani is restricted to the area near the pubis. By 12 weeks, the levator ani also obtains attachment to the ischial spine immediately ventral to the coccygeus muscle. The most superior part of the coccygeus muscle occupies a space at an angle between the pelvic splanchnic and pudendal nerves. Notably, medial to the coccygeus muscle, a third parasagittal muscle (previously termed the sacrococcygeus anterior) appears by 12 weeks, increases in mass by 18 weeks, and connects and mixes with the dorsal end of the levator ani by 18-20 weeks. Thus, the coccygeal attachment of the levator ani appears not to depend on the dorsal extension of the muscle itself but on fusion with the sacrococcygeus anterior. Therefore, the final levator sheet is formed medial (internal) to the coccygeus muscle and originates from two distinct anlage.

Using 15 mid-term human fetuses, we examined the role of the spine anterior and posterior longitudinal ligaments (ALL, PLL) in ossification of the lumbar vertebral body. By 18 weeks, a pair of calcified tissue or cortical walls had developed on the anterior and posterior sides of the ossification center. These calcified cortical walls were more highly eosinophilic than trabecular or woven bone in the ossification center. Vimentin-positive osteoblasts were arranged in line along the outer surface of the walls. However, few CD68-positive osteoclasts were evident around the walls, suggesting that the calcification in the walls was similar to periosteal ossification. The anterior cortical wall was connected tightly with the ALL by fiber bundles, but the posterior wall was separated from the PLL by the basivertebral (central) vein and loose tissues. Notably, by 30 weeks, the anterior cortical wall had become attached to and incorporated into the ALL. Thus, the ALL seemed to act as an active periosteum for ossification. Although our materials were limited in number and stage, we hypothesized that, in contrast to the PLL, the mature anterior cortical wall corresponds to a calcified fibrocartilage adjacent to the ALL and forms a bone-ligament interface maintaining an ossification potential.

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Rationale:Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown.Patient concerns:We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank.Diagnoses:The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy.Interventions:The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap.Outcomes:No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively.Lessons:In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.